Intake Form

Name*
First Middle Last
Birth Date*
Social Security Number (Last Four)*
Status*
- Single
- Married
- Divorced
- Widowed
Cell Phone*
Secondary or Home Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Employer*
Occupation*
Work Phone*
Primary Care Physician:*
Primary Care Physician Phone*
Emergency Contact Name*
First Last
Relationship to Patient*
Emergency Contact Phone*
Family member's seen at this office:*
Reason for visit?*
Insurance Information
Vision Insurance Carrier:*
Policy #*
Group #*
Policy Holder:*
Social Security # (last four):*
Date of Birth:*
Primary Medical Carrier:*
Policy #*
Group #*
Policy Holder:*
Social Security # (last four):*
Date of Birth:*
Secondary Medical Carrier:
Policy #
Group #
Policy Holder:
Social Security # (last four):
Date of Birth:*
Vision History
Do you have the following? If your answer is yes, please provide the date of last occurrence.
Double Vision*
- Yes
- No
If yes, provide date of last occurrence:*
Dry Eyes*
- Yes
- No
If yes, provide date of last occurrence:*
Eye Drops*
- Yes
- No
If yes, provide date of last occurrence:*
Eye Infection*
- Yes
- No
If yes, provide date of last occurrence:*
Eye Strain*
- Yes
- No
If yes, provide date of last occurrence:*
Flashes of Light*
- Yes
- No
If yes, provide date of last occurrence:*
Frequent Headaches*
- Yes
- No
If yes, provide date of last occurrence:*
Head Injury*
- Yes
- No
If yes, provide date of last occurrence:*
Ocular Allergies*
- Yes
- No
If yes, provide date of last occurrence:*
Ocular Surgery*
- Yes
- No
If yes, provide date of last occurrence:*
Problem with Night Vision*
- Yes
- No
If yes, provide date of last occurrence:*
Problem with Sunlight/Day*
- Yes
- No
If yes, provide date of last occurrence:*
When was your last eye exam?*
Location of your last eye exam?*
Contact Lenses
Have you worn contact lenses before?*
- Yes
- No
If yes, last time worn?*
Of yes, what kind of contact?*
- Daily
- Two week
- Monthly
- Rigid gas permeable
If yes, overnight use?*
- Never
- Occasional
- Frequent
If yes, average wear time?*
Are you satisfied with your current contacts?*
- Yes
- No
Interests and Hobbies
Do you enjoy any of the following activities/hobbies?*
- Biking
- Computer
- Fishing
- Gardening
- Golf
- Hiking
- Hunting
- Reading
- Sewing/knitting
- Skiing/snowboarding
- Swimming
- Video gaming
- Water sports
- Other
If other, explain?*
Sunglasses
Is UV protection important to you?*
- Yes
- No
Do you currently own sunglasses?*
- Yes
- No
On average, how much time per day do you spend outside in direct sunlight?*
- None
- 30 minutes to 1 hour
- 2 to 4 hours
- More than 4 hours
How do you currently protect your eyes from harmful UV rays?*
Screen Time
How many hours per day do you spend on the following devices?
Computer:*
Tablet:*
Smart Phone:*
Television:*
Medical History
Do you and/or members of your family have the following? Please check the box and provide the date of last occurrence for all that apply. For family members, please indicate the relationship.
Diabetes*
- Yes
- No
If yes, were you or a family member diagnosed with diabetes?*
- You
- Family member
If you were diagnosed, what is the date of the last occurrence?*
If a family member was diagnosed, what is their relationship to you?*
High Blood Pressure*
- Yes
- No
If yes, were you or a family member diagnosed with high blood pressure?*
- You
- Family member
If you were diagnosed, what is the date of the last occurrence?*
If a family member was diagnosed, what is their relationship to you?*
Heart Problems*
- Yes
- No
If yes, were you or a family member diagnosed with heart problems?*
- You
- Family member
If you were diagnosed, what is the date of the last occurrence?*
If a family member was diagnosed, what is their relationship to you?*
Asthma*
- Yes
- No
If yes, were you or a family member diagnosed with asthma?*
- You
- Family member
If you were diagnosed, what is the date of the last occurrence?*
If a family member was diagnosed, what is their relationship to you?*
Cataracts*
- Yes
- No
If yes, were you or a family member diagnosed with cataracts?*
- You
- Family member
If you were diagnosed, what is the date of the last occurrence?*
If a family member was diagnosed, what is their relationship to you?*
Retinal detachment*
- Yes
- No
If yes, were you or a family member diagnosed with retinal detachment?*
- You
- Family member
If you were diagnosed, what is the date of the last occurrence?*
If a family member was diagnosed, what is their relationship to you?*
Glaucoma*
- Yes
- No
If yes, were you or a family member diagnosed with glaucoma?*
- You
- Family member
If you were diagnosed, what is the date of the last occurrence?*
If a family member was diagnosed, what is their relationship to you?*
Lazy or crossed eyes*
- Yes
- No
If yes, were you or a family member diagnosed with lazy or crossed eyes?*
- You
- Family member
If you were diagnosed, what is the date of the last occurrence?*
If a family member was diagnosed, what is their relationship to you?*
Macular degeneration*
- Yes
- No
If yes, were you or a family member diagnosed with macular degeneration?*
- You
- Family member
If you were diagnosed, what is the date of the last occurrence?*
If a family member was diagnosed, what is their relationship to you?*
Other ocular problems*
- Yes
- No
If yes, were you or a family member diagnosed with other ocular problems?*
- You
- Family member
If you were diagnosed, what is the date of the last occurrence?*
If a family member was diagnosed, what is their relationship to you?*
Are you currently taking any medications?*
- Yes
- No
If yes, please list:*
Do you have any medicine allergies?*
- Yes
- No
If yes, please list:*
Do you drink alcohol?*
- Yes
- No
If yes, how many drinks per week?*
Do you use tobacco?*
- Yes
- No
If yes, what type?*
If yes, amount?*
Are you currently pregnant?*
- Yes
- No
Billing Insurance
Vision insurance and Medical insurance are very different in terms of services they cover. It is important for our patients to understand those differences. Vision coverage is mainly designed to determine a prescription for glasses or contact lenses and is not equipped to deal with complex medical conditions and/or diagnosis. It does allow for screening of conditions, but once they are determined, then medical insurance is filed on those services. When a medical condition is present (such as diabetes, cataracts, dry eyes, floaters, etc.) it is necessary to file the visit with your medical insurance, the co-pays, deductible, and coinsurance for that insurance will apply as well as the non-covered service. Insurance carriers set these rules and our office is obligated to follow them. In most cases, there is no way to know prior to the examination which type of insurance our office will be able to file for you. We make every effort to be in-network with every major insurance carrier for your convenience and we will file those claims for you. In the event that we do not take your insurance, we will provide you with an itemized receipt so that you may file with your carrier for reimbursement. If you have any questions, please let us know.
I understand the paragraph above and authorize Owen Eye Care to file my insurance by the above guidelines.
Signature*
Date*
MM slash DD slash YYYY
Privacy of Information and HIPAA Notification
Consent*
I acknowledge that I received a copy of Owen Eye Care Inc. Notice of Privacy Practices regarding how medical
information pertaining to my eye care may be used and disclosed and how I can access this information.
I agree.
Signature*
Name*
First Last
Date*
MM slash DD slash YYYY

Intake Form

Intake Form

Insurance Information

Vision History

Contact Lenses

Interests and Hobbies

Sunglasses

Screen Time

Medical History

Billing Insurance

Privacy of Information and HIPAA Notification